ALLAN GRAY ORBIS FOUNDATION

FELLOWSHIP APPLICATION FORM 2011

___________________________
ST
FOR STUDENTS CURRENTLY IN 1 YEAR UNIVERSITY

PREREQUISITES:

Indication of entrepreneurial flair and passion,

Citizenship of South Africa, Namibia, Botswana or Swaziland,

Belief in the future of your country,

Ambassador of the Foundation’s intended profile, namely demonstrating: intellectual imagination, personal
initiative, spirit of selflessness, courageous commitment and achievement excellence,

Studying for a commerce, science (excluding medicine), engineering, law or humanities (majoring in Politics,
Philosophy OR Economics) degree at WITS, UJ, UCT, NMMU, Rhodes, UWC, UP or Stellenbosch University.

Minimum of 65% Average in 2011 mid-year exam results,

Certified copies of Academic/extra-curricular awards/recognition must be provided,
st

Candidates must not be older than 22 years of age on 31 August 2011.

APPLICATION DEADLINE:
31ST AUGUST 2011BY 12H00
 Post to:
Allan Gray Orbis Foundation
Freepost no: CB 11349
Waterfront
8002
Important note to Applicants
Application Deadline: 31st August 2011 by 12h00

• The Allan Gray Orbis Foundation seeks to promote prosperity through entrepreneurship in an integrated Southern
Africa. The Foundation aims to achieve this mission by identifying, educating and equipping demographically diverse
individuals who have the potential to excel and make a significant future impact as high impact entrepreneurial leaders.

• All information requested by the Allan Gray Orbis Foundation will be kept confidential. The Allan Gray Orbis
Foundation will not disseminate any personal information unless specifically authorised on page12 of this application.

• Submission of this application form to the Allan Gray Orbis Foundation does NOT automatically guarantee that you
(the applicant) will be awarded the Allan Gray Fellowship. Applicants are encouraged to make applications to other
scholarships and/or bursaries in order to avoid disappointment should this application be unsuccessful.

• Faxed and/or e-mailed copies of the application form will NOT be accepted. Please ensure that you submit the
application form in good time, in order to meet the application deadline. Application forms received after 31st August
2011 (12H00) will NOT be considered.

• Please return this application form together with all the supporting documents to the postal address above. You will
be notified via-SMS when your application form has been received by the Allan Gray Orbis Foundation.

• Please retain a copy of your completed application form and other relevant documents for your own records.

• Applicants will be notified of their status throughout the selection process. This means that if you have not heard
from us, we are still busy processing applications.

• Allan Gray Orbis Foundation contact details: Tel: 011 994 9860
Email: fellowship@allangrayorbis.org
Website: www.allangrayorbis.org

The Selection Process

st
Step 1 Submit completed Application Form 31 August
Step 2 Shortlisted applicants invited to a face to face interview October
Step 3 Shortlisted candidates invited to a Selection Camp December Holidays

Please note that Applicants will be contacted after each step of the Selection Process to notify them of their
application status.

Page 2 of 18 pages
 Attachment Checklist
Please ensure that you have met all the requirements for completing this application. Incomplete applications
will NOT be considered. The following documents need to be attached to your application form:

Certified copy of your ID

Certified copy of your June 2011 Exams results
Certified copy of your final Grade 12 report
Certified copies of Academic/Extra-curricular awards/recognition/supporting documentation
Stamped and signed reference from an Educator / Faculty Representative AND a Leader in the community

For Official Use:

Application Reference
Number:
1000-1____________

Eligible / Ineligible

Page 3 of 18 pages
APPLICATION FORM

Have you applied for this Fellowship before? Yes No

1. APPLICANT (Factual information about yourself)

Title: Mr / Miss (Please circle the appropriate option) First name(s):

Surname: Middle Names:

Date of birth: D | D | M | M | Y | Y | Y | Y Gender: Male / Female

(Please circle the appropriate option)

Country of citizenship: Race: Black / White / Coloured / Indian / Asian

(Please circle the appropriate option)

ID / Passport No:

Home Address Postal address

Street Name & No: P.O Box

Suburb / Township / Village: Suburb / Township / Village:

City: City:

Province: Province:

Country: Country:

Postal Code: Postal Code:

Home phone: Cell:

E-mail Address: Home language:

Second language: Other languages:

Preferred method of contact: Post / Email / Home phone / Cell

(Please circle the appropriate option)

2. EMERGENCY CONTACT DETAILS (Should we need to contact you urgently)

Title: Mr / Mrs / Ms / Dr (Please circle the appropriate option)

First name(s): Surname:

1st contact number: Relationship to applicant:

(e.g. Mother, Father, Aunt)
2nd contact number:

Page 4 of 18 pages
3. PARENT OR GUARDIAN DETAILS (1) (Information about your parent or legal guardian)
Title: Mr / Mrs / Ms / Dr (Please circle the appropriate option) First name(s):

Surname: Date of birth: D | D | M | M| Y | Y | Y | Y

Parent / Guardian
Country of citizenship:
(Please circle the appropriate option)

Relationship to applicant: Marital status: Single / Married / Divorced / Widowed

(e.g. Mother, Father, Aunt) (Please circle the appropriate option)

ID / Passport No: Occupation:

Home Address
Street Name & No: Suburb / Township / Village:

City: Province:

Country: Postal Code:

E-mail address:

Home phone: Cell:

Work phone: Fax:

Preferred method of contact: Post / Email / Home phone / Work phone / Cell
(Please circle the appropriate option)

PARENT OR GUARDIAN DETAILS (2) (Information about your parent or legal guardian)
Title: Mr / Mrs / Ms / Dr (Please circle the appropriate option) First name(s):

Surname: Date of birth: D | D | M | M| Y | Y | Y | Y

Parent / Guardian
Country of citizenship:
(Please circle the appropriate option)

Relationship to applicant: Marital status: Single / Married / Divorced / Widowed

(e.g. Mother, Father, Aunt) (Please circle the appropriate option)

ID / Passport No: Occupation:

Home Address
Street Name & No: Suburb / Township / Village:

City: Province:

Country: Postal Code:

E-mail address:

Home phone: Cell:

Work phone: Fax:

Preferred method of contact: Post / Email / Home phone / Work phone / Cell
(Please circle the appropriate option)

Combined monthly household income of parent(s) and / or guardian(s) before deductions: (Please tick the relevant box)

R0 – R6 000, R6 000 – R11 999, R12 000 – R23 999, R24 000 – R35 999, > R36 000

Page 5 of 18 pages
4a. ACADEMIC HISTORY: University (Please ensure that a certified copy of your school results is included with your application)
University name:

Student number:

Degree path/major/specialisation:
Faculty: Year of study:
Course (Mid Year) Results Course % Date Course (Mid Year) Results Course % Date
Code Code

4b. ACADEMIC HISTORY: School (Please ensure that a certified copy of your school results is included with your application)
School name:
Type of School (Select 1 or more options as appropriate)

Private Public Ex-Model C

Girls Only Boys Only Co-Ed

School Address
Where was your school located?

Suburb Township Village Rural Area

Street Name: Province:

Country: Postal Code:

Telephone number: Grade 12 Completion Year:

Final Grade 12 results: (Please complete the table) Position in grade: No. of pupils in grade:

Subject % Date Subject % Date

Mathematics

List academic awards and/or recognition: (Please attach supporting documentation with your application)

5. INTENDED POSTGRADUATE STUDIES

Order of
Faculty Name of degree University
preference
1
2
3

Page 6 of 18 pages
 6. EXTRAMURAL ACTIVITIES (Please list any achievements or awards at High School, University or community)
Leadership: Please indicate current or previous leadership roles.
Institution Position Year Reference
(e.g. High School / University) (e.g. Member of RCL) (e.g. 2005) (e.g. Mr AN Other)

Community service/involvement: Please indicate any community involvement in which you participate or have participated.
Organisation Nature of involvement Duration of involvement Reference
(e.g. Rotary Club) (e.g. Secretary) (e.g. 2 years) (e.g. Ms SM Body)

Sport: Please indicate the sports that you play regularly, and the highest level obtained.
Sport Level Provincial / National Reference
recognition
(e.g. Soccer) (e.g. School 1st team) (e.g. Gauteng province side) (e.g. Mrs J Doe)

Cultural: Please list your main cultural activities (music, dancing etc.).
Activity Level Awards obtained Reference
(E.g. Choir) (E.g. Lead singer) (E.g. School Best Soloist) (E.g. Mr A Singer)

List extra-curricular awards or recognition: (Please attach supporting documentation with your application)

What are your hobbies? What do you do in your spare time?

What would you do in your ideal week?

Page 7 of 18 pages
7. WHO ARE YOU?
7.1 a) Tell us about yourself and your family, including both your parents’ (or guardian’s) current occupation.

b) Who has played an important role in your upbringing, and how has this person done so?

7.2 What have you done or achieved that makes you stand out in your community or school? Give 1 example

7.3 a) What informed your decision to study towards your chosen degree and what research did you conduct to help
you make the decision?

b) How do your interests and passion connect to your chosen career / degree?

Page 8 of 18 pages
7.4 Describe a situation where you demonstrated leadership abilities in your school or community.

7.5 How are you demonstrating excellence in other areas of your life outside of your academic achievements? In
what way/s has this been recognised?

7.6. Describe a project or activity that you personally started during the last 5 years or where you played a key /
significant role. What role did you play? How did you prepare for it? What was the impact of the project or activity?

Page 9 of 18 pages
7.7. What is your understanding of an entrepreneurial mindset?

7.8 According to the latest statistics, Africa’s population exceeded 1 billion people in 2010. With your understanding
of an entrepreneurial mindset (Q7.7), mention one creative and sustainable business opportunity that you can come
up with to benefit your country

7.9 Mention one stressful event (obstacle) that you experienced in your life:
a) How did you respond to the event and what actions (steps) did you take?

b) How did this event impact you and what lessons did you learn?

Page 10 of 18 pages
7.10 a) What is the South Africa you want to see in the next 10 years?

b) What will your contribution be towards the South Africa that you want to see in the next 10 years?

Page 11 of 18 pages
 WHERE DID YOU HEAR ABOUT US?
Please tick the box(es) that apply and provide any specific information in the space provided below:

Allan Gray Orbis Foundation Website

An Allan Gray Fellow told me about it
Campus Presentation
SMS
Email (I received an email with the details)
Facebook
Twitter
Career Guidance Office
Financial Aid Office
The Bursary Register
Allan Gray Orbis Foundation E-Zine
Other (Please specify)

Specify here:

WHAT ORGANISATIONS OR INITIATIVES HAVE YOU BEEN INVOLVED IN AT

UNIVERSITY?
Please tick the box(es) that apply and provide any specific information in the space provided below

Black Management Forum (BMF) Toastmasters

Investment Society (Investsoc) Other

Specify here:

STATEMENT OF INTEGRITY
I hereby certify that I have provided accurate information in this application. I authorise all persons or entities to provide any
relevant information in their possession to the Allan Gray Orbis Foundation or its agent for use in considering me for admission or
verifying my credentials for admission, and I expressly waive any required notice to me. I understand and agree that any
misrepresentation or omission of facts in my application will justify denial of admission, the cancellation of admission, or
expulsion.

I hereby grant permission to Allan Gray Orbis Foundation to utilise the information provided in this application for the purposes of
the Foundation’s activities.

This application is my own honest statement to the Admissions Committee.

Applicant’s signature: Date: D | D | M | M | Y | Y | Y | Y

Parent/Legal guardian’s signature: Date: D | D | M | M | Y | Y | Y | Y

The Allan Gray Orbis Foundation is proud to have partnered with various funding organizations working with(in)
universities and other related projects. These partners share an interest in providing further opportunities to candidates who
show potential within the Foundation selection process but who are not ultimately successful as Allan Gray Fellows. While
these alternative opportunities are by no means guaranteed, would you consent to the Foundation communicating your
rd
personal particulars to these 3 parties?

Please tick this box if you agree to this:

Please return this application form together with all the supporting documents to:
st
Allan Gray Orbis Foundation Application Deadline: 31 August 2011 by
12h00
Freepost no: CB 11349
Waterfront
Page 12 of 18 pages
 OFFICIAL RELIGIOUS /
COMMUNITY ORGANISATION
STAMP

REFERENCE FROM LEADER IN COMMUNITY

Important: In order to ensure confidentiality of this reference letter, please submit it to the candidate in question
in a sealed A5 envelope. Your signature and Organisation’s Stamp must appear across the seal. Reference letters
that do not comply with this requirement will not be considered

I, the undersigned, confirm the following concerning the applicant:

Applicant First Name: Surname:

Number of years that I have known the applicant:

Describe the applicant’s family situation:

Describe the applicant’s involvement and participation in the activities of your religious / community organisation:

What are the unique attributes / characteristics / qualities of the applicant?

Have you witnessed the applicant contributing to the well-being of others? Give examples
Example 1:

Example 2:

Page 13 of 18 pages
 Have you witnessed the applicant demonstrating emotional intelligence*? Give an example

* Emotional Intelligence: The ability to recognise, assess and manage one’s own emotions and those of others in a
healthy and productive manner.

Put a tick next to the statement/s that you feel best describes the applicant’s behaviour
Agree Strongly Agree Neutral Disagree Disagree Strongly

Demonstrates self awareness consistently

Is able to control his/her emotions

Is able to manage others’ emotions

Having read the application criteria overleaf, I recommend this applicant for the Allan Gray Fellowship because:

This reference was given by me, the undersigned, in my capacity as:

Religious/community organisation:

Title: Mr / Mrs / Dr (Please circle the appropriate option) Current Position:

First Name(s): Surname:

Telephone number: Cell number:

Email: Organisation Website:

Signature Date: D | D | M | M | Y | Y | Y | Y

Page 14 of 18 pages
Allan Gray Orbis Foundation – 5 Pillars

The Allan Gray Orbis Foundation is looking for individuals who carry the following characteristics as they start their journey
towards entrepreneurial endeavour:

An enquiring and active mind demonstrated by an

established record of intellectual achievement. An
Intellectual Imagination
ability to see the unseen, challenge the status quo
and suggest that things could be done differently to
create new opportunities.

A person that makes things happen and celebrates

Personal Initiative the satisfaction of bringing new things into being.
Independent, proactive and self starting. A person
that is willing and able to make their own decisions.

A weight of personality that comes from living a life

personified by passion and integrity. Recognition that
Spirit of Selflessness ultimate personal satisfaction comes from
empowering oneself in order that one might be able
to serve others.

The courage and dedication to continue, realising

Courageous Commitment
that applying consistent commitment has a way of
overcoming.

The on-going pursuit of excellence with a tangible

and specific focus on setting goals. A motivation to
Achievement Excellence
make a difference and leave a mark. To be bold, not
looking back, but pressing forward in the pursuit of
ones goals.

Page 15 of 18 pages
 OFFICIAL SCHOOL / UNIVERSITY
STAMP

REFERENCE FROM EDUCATOR / FACULTY REPRESENTATIVE

Important: In order to ensure confidentiality of this reference letter, please submit it to the candidate in question
in a sealed A5 envelope. Your signature and School/ University Stamp must appear across the seal. Reference
letters that do not comply with this requirement will not be considered

I, the undersigned, confirm the following concerning the applicant:

Applicant First Name: Surname:

Number of years that I have known the applicant:

Comment on each of the following about the applicant:

• Intellectual ability and application of intellect in imaginative ways:

• Leadership and courageous qualities:

Have you witnessed the applicant contributing to the well-being of others? Give examples
Example 1:

Example 2:

Have you witnessed the applicant demonstrating emotional intelligence*? Give an example

*Emotional Intelligence: The ability to recognise, assess and manage one’s own emotions and those of others
in a healthy and productive manner. Page 16 of 18 pages
Put a tick next to the statement/s that you feel best describes the applicant’s behaviour.

Agree Strongly Agree Neutral Disagree Disagree Strongly

Demonstrates self awareness consistently

Is able to control his/her emotions

Is able to manage others’ emotions

Having read the application criteria overleaf, I recommend this applicant for the Allan Gray Fellowship because:

This reference was given by me, the undersigned, in my capacity as:

University / School Name:

Title: Mr / Mrs / Dr (Please circle the appropriate option) Current Position:

First Name(s): Surname:

Telephone number: Cell number:

Email:

Signature Date: D | D | M | M | Y | Y | Y | Y

Page 17 of 18 pages
Allan Gray Orbis Foundation – 5 Pillars

The Allan Gray Orbis Foundation is looking for individuals who carry the following characteristics as they start their journey
towards entrepreneurial endeavour:

An enquiring and active mind demonstrated by an

established record of intellectual achievement. An
Intellectual Imagination
ability to see the unseen, challenge the status quo
and suggest that things could be done differently to
create new opportunities.

A person that makes things happen and celebrates

Personal Initiative the satisfaction of bringing new things into being.
Independent, proactive and self starting. A person
that is willing and able to make their own decisions.

A weight of personality that comes from living a life

personified by passion and integrity. Recognition that
Spirit of Selflessness ultimate personal satisfaction comes from
empowering oneself in order that one might be able
to serve others.

The courage and dedication to continue, realising

Courageous Commitment
that applying consistent commitment has a way of
overcoming.

The on-going pursuit of excellence with a tangible

and specific focus on setting goals. A motivation to
Achievement Excellence
make a difference and leave a mark. To be bold, not
looking back, but pressing forward in the pursuit of
ones goals.

Page 18 of 18 pages